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Satisfaction Survey
Welcome! Please take a few moments to complete this brief survey.
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1
Name of person completing this survey.
*
This field is required.
First Name
Last Name
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2
What is your relationship to our office?
Client
Healthcare Office
Parent/Guardian/Family Member
Community Service Organization
Other
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3
What services were received from our office?
Counseling
Primary Care/ Medical Services
Medication Management
Community Support
Telehealth Medicine
Psychological Testing
Substance Abuse Treatment/Evaluation
Other
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4
Name of provider(s)
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5
Name of treating provider.
Select all that apply.
Debra Erickson
Jordan Hofmann
Abby Gleason
Alexis Bloomfield
Amanda Schmidt
CeCe Bacon
Chantal Kohl
Cheryl Lockett
Christopher Sanders
Christy Freehling
Cindy Betka
Dave Hoyt
Emma Todd
Laurie Robinson
Raquel Moreno-Izaguirre
Sara Gasper
Sarah Bennett
Suzanne Riley
Other
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6
Overall satisfaction
Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
Provider
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Waiting Time
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Front Desk Staff
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Success of Treatment
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Scheduling/Communication
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Comfort of Environment
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Accommodations of Needs
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Billing Procedures
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Provider
Waiting Time
Front Desk Staff
Success of Treatment
Scheduling/Communication
Comfort of Environment
Accommodations of Needs
Billing Procedures
Very satisfied
Row 0, Column 0
Satisfied
Row 0, Column 1
Neutral
Row 0, Column 2
Unsatisfied
Row 0, Column 3
Very unsatisfied
Row 0, Column 4
Very satisfied
Row 1, Column 0
Satisfied
Row 1, Column 1
Neutral
Row 1, Column 2
Unsatisfied
Row 1, Column 3
Very unsatisfied
Row 1, Column 4
Very satisfied
Row 2, Column 0
Satisfied
Row 2, Column 1
Neutral
Row 2, Column 2
Unsatisfied
Row 2, Column 3
Very unsatisfied
Row 2, Column 4
Very satisfied
Row 3, Column 0
Satisfied
Row 3, Column 1
Neutral
Row 3, Column 2
Unsatisfied
Row 3, Column 3
Very unsatisfied
Row 3, Column 4
Very satisfied
Row 4, Column 0
Satisfied
Row 4, Column 1
Neutral
Row 4, Column 2
Unsatisfied
Row 4, Column 3
Very unsatisfied
Row 4, Column 4
Very satisfied
Row 5, Column 0
Satisfied
Row 5, Column 1
Neutral
Row 5, Column 2
Unsatisfied
Row 5, Column 3
Very unsatisfied
Row 5, Column 4
Very satisfied
Row 6, Column 0
Satisfied
Row 6, Column 1
Neutral
Row 6, Column 2
Unsatisfied
Row 6, Column 3
Very unsatisfied
Row 6, Column 4
Very satisfied
Row 7, Column 0
Satisfied
Row 7, Column 1
Neutral
Row 7, Column 2
Unsatisfied
Row 7, Column 3
Very unsatisfied
Row 7, Column 4
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7
How can we improve our service?
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8
Would you like us to contact you regarding your satisfaction with our office?
YES
NO
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9
If you would like us to contact you regarding your satisfaction with our office, please provide your name phone number.
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10
Date of survey
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Date
Month
Day
Year
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